HospitalInspections.org

Based on review of Emergency Staff credential files, review of Medical Staff Bylaws, review of Emergency Staff On-Call schedules and interview, it was determined 1 (#1) of 8 (#1-#8) Emergency Room Staff did not have privileges approved by the Governing Body, to work in the Emergency Room. The failed practice did not assure the Governing Body approved the qualifications and demonstrated competency for the physician and had the potential to affect all patients presenting to the Emergency Room. Findings follow:

A. Review of the credential file for Physician #1 revealed no evidence privileges to work in the Emergency Room were requested.

B. Review of Medical Staff Bylaws presented by the Administrator on 03/27/14 at 1600 revealed all applications shall be ...submitted on a form prescribed by the Governing Body ...specific requests stating the staff category and clinical privileges requested.

C. Review of the On-Call schedule for the Emergency Room provided by the Director of Emergency Room for the month of March, 2014, revealed Physician #1 was assigned to work the evening shift on 03/25/14.

D. Findings were verified during interview with the Medical Staff Coordinator on 03/27/14 at 1410.